What Is Stuttering?

I stuttered severely. I needed an hour to say what a non-stutterer could say in ve minutes. I could block on a word for ve minutes. My speech wasnt just slow. I jerked my head, rolled my eyes, and my body shook in spasms. Some listeners asked if I needed medical attention. More often they laughed at me. Worst, my speech was incomprehensible. Listeners guessed what I was trying to say, usually wrong. Or they ignored me and walked away. Im now forty-six. People ask me to speak at events. I perform acting and stand-up comedy. In stressful conversations I sound condent and relaxed. And I still stutter. Stuttering is a remarkable disorder. Its easy to treat, andpast the age of sixdifcult or impossible to cure. Stutterers can talk uently when theyre alone, or by changing their style of speaking, by focusing their attention on certain parts of speech, by using an electronic device, or even seeing their speech therapist walk into the room. But stutterers can go right back to stuttering, even after months of the best therapy. Temporary snake oil cures are a dime a dozen, but a universal, permanent treatment has never been found. Stuttering occurs when we want most to speak well, such as job interviews, public speaking, or speaking to authority gures. Stuttering is characterized by overtense speech-production muscles. We try too hard, tense, stutter, try harder, stutter more, and get stuck in a vicious cycle. The most frustrating aspect of stuttering is that it gets worse when we try not to do it. Some stutterers have extreme physical symptoms, as I did. Other stutterers hide their stuttering by substituting or avoiding 14

What Is Stuttering?

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words, but are disabled by speech-related fears and anxieties. A stutterer may refuse promotions that require talking, or avoid social interaction. Not many paraplegics win marathons. Few blind persons become famous painters. Not a lot of deaf persons are great musicians. But despite the disabling effects of stuttering, some stutterers become effective public speakers. Demosthenes was the greatest orator of ancient Greece. Aesop was master storyteller of Babylon. Winston Churchill and Aneurin Bevan were the best speakers in the British Parliament in the 1930s. Today, James Earl Jones is the most in-demand voice in Hollywood. These stutterers found ways to speak uently, and developed these techniques into strengths. Demosthenes improved his articulation by speaking with pebbles in his mouth, improved his volume by shouting over the ocean waves, and worked with an actor to speak with emotional affect. Bevan also found uency when expressing his emotions. As leader of the British Labor Party during the Depression he made passionate speeches about the plight of the working class. Churchill was uent when he prepared his remarks in advanceso he devoted long hours to mastering every political issue and having an answer ready for every objection. Jones recited Shakespeare and developed his acting talent along with his uency. Individuals nd their strengths only after nding their limitations.22 For others, 35 may be when the dreams of their youth crash down. But for stutterers this is often the age at which they overcome stuttering, and nd that they can achieve goals they never thought possible. Stutterers are both hyperaware and unaware of stuttering. Before talking to a stranger, we have fear and anxiety that well lose control of our speech. But we have poor awareness of what do when we stutter. Speech therapy often begins with the stutterer

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No Miracle Cures

analyzing videotapes of his speech and seeing for the rst time what he does when he stutters. You cant overcome stuttering until you admit that you stutter. Ironically, admitting that you stutter gets easier as you improve your uency. People who stutter severely can be the least willing to do anything about their stuttering. But after you make progress on your speech, you want to tell everyone how you did it. You attend support groups and stuttering conventionsor write a book. Stuttering is one of few disabilities that get better over time. Most children outgrow it. Even adults who stutter severely in their 20s usually learn to manage their stuttering in their 30s. Other diseases lead to a lifetime of worsening symptoms. But if youre an adult stutterer, your most severe stuttering is probably behind you. Stuttering is difcult to treat because it involves all aspects of your lifemuscle control, emotions and anxieties, cognitive awareness, and social interaction. By working on the different aspects of stuttering, your reward is not just uent speech, but improvements in all areas of your life. Years after reading this book, youll look back over many life successes and say that stuttering was a gift.
In no area is man more vulnerable to misunderstanding, criticism and downright abuse from his fellow man than if he should fail to develop speech, or having gained it, should lose itfor when man loses the ability to express himself by speech he is suspectof having lost, also the [faculties to arrive] at the conclusions which he would express in speech. The world feelsthat if he cant say his namehe doesnt know his name.23

Denition of Stuttering Stuttering is repetition and prolongation of sounds and syllables, and silent blocks in which the stutterers vocal folds close and prevent the release of air and the production of sound, that nega-

What Is Stuttering?

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tively affects the pace, clarity, and prosody (emotional content) of speech. Stuttering includes abnormally high activity in the speech production muscles, specically respiration, vocal folds, and articulation (lips, jaw, and tongue). Stuttering is involuntary. Stuttering typically occurs on the first words of a sentence, and the first sounds of words. Children and adults typically stutter on longer words. Adults typically stutter on content or pragmatic words (typically nouns, verbs, adjectives, and adverbs), that carry more meaning than function words such as pronouns, prepositions, or conjunctions. Stuttering also tends to occur on less frequently used words.24 Stuttering also often includes struggle behavior, in which the stutterer tries harder to speak, increases his speech-production muscle tension, and stutters more severely. How Fluent Speech Is Produced Speech begins with breathing, also called respiration. Your lungs ll with air, more air than you would inhale if you werent talking. You expand your upper chest and your diaphragm (belly) to get all this air in. Your lung pressure and respiration muscle tension increase. Next, you release air through your throat, past your vocal folds (also called vocal cords). Your vocal folds are a pair of small muscles in your larynx. If you tense these muscles slightly, and release a little air, your vocal folds vibrate. This is called phonation. Its also called the fundamental frequency of your voice. If you place your ngers on the front of your throat, then hum or talk, you can feel your vocal folds vibrating. Adult men vibrate their vocal folds about 125 Hz (125 times per second). Women vibrate their vocal folds about 200 Hz. Childrens voices are even higher. This is too fast for your brain to control. Vocal fold vibration is the only muscle activity that your brain doesnt directly control. Instead, phonation results from the coordination of respiration muscles to release air with slight tensing of your vocal fold muscles.

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No Miracle Cures

The key word in that last sentence was coordination. Stuttering is largely a disorder of poorly coordinated speech production muscles. If you tense your vocal folds too much, you block off your throat and stop air from escaping your lungs. This is a good when lifting heavy weights. By blocking your larynx and tensing your respiration muscles, you increase lung pressure, which strengthens your chest and you can lift more weight. Similarly, tires inated to high pressure can carry a heavier car. Thats what stutterers do when they talk, and its not a good idea. The space in your throat above your larynx is called the pharynx. Above your pharynx are your oral and nasal cavities. These spaces create vocal resonation. This is like the echoing of a cathedral or tunnel. The unique shape of these spaces makes each of our voices sound unique. Your jaw and lips and tongue, collectively called the articulation muscles, modify your voice into intelligible speech. Vowels and voiced consonants (such as /b/ and /d/) are produced by your vocal folds, and modied by your articulation muscles (jaw, lips, tongue). Other consonants are voiceless, such as /p/ and /t/, produced by your articulation muscles modifying airow, without your vocal folds vibrating. When you whisper, you dont vibrate your vocal folds. You just modify airow with your articulation muscles. Speech requires coordination of over 100 muscles. The average person speaks about 150 words per minute. Each word requires a different conguration of most of those muscles. Speech is our most complex neuromuscular activity. Core Stuttering Behaviors Disordered breathing, including antagonism between abdominal (belly) and thoracic (upper chest) respiratory muscles; complete cessation of breathing, and interrupting exhalation with inhalation. Disordered vocal folds, including high levels of muscle activ-

What Is Stuttering?

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ity or muscle tension; poor laryngeal muscle timing, such as starting phonation too late or holding tension too long; and poor coordination of laryngeal muscles, e.g., incompatible contractions of opposing muscles. Disordered articulation, including dysfunctions of the lips, jaw, and tongue in stuttering. In general, stutterers place their articulators in the right positions (in contrast to other speech disorders such as lisping), but time the movements wrong.

Secondary Stuttering Behaviors Secondary stuttering behaviors are unrelated to speech production: Gross (large) muscle movements such as eye-blinking, head jerks, body spasms, gasping, clenching of teeth or sts. Fear of certain words or sounds, avoidance of feared words, substitution of another word, or postponement of a feared word by adding pauses or ller words. Interjected starter sounds and words, such as um, ah, you know, or in other words. Repeating a sentence or phrase to get a running start. Vocal abnormalities to prevent stuttering, such as speaking in a rapid monotone, affecting an accent, or using odd inections. Looking away, not maintaining eye contact. Articulating an unrelated sound, e.g., forming a /t/ sound when trying to say /s/. Low-frequency tremors in the neck, jaw, and lip muscles of adult stutterers. These are found to a lesser extent in older children, and not found in young children who stutter.25

The stutterer initiates secondary behaviors to distract his attention from his speech-production muscles, leading to his speechproduction muscles relaxing and producing the intended word. However, the secondary behaviors soon become part of stuttering.

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No Miracle Cures

I remember my mother telling me that if I could just stop the head jerks and body spasms my stuttering would be more tolerable to listeners, but I had no more control of my secondary behaviors than I had of the core stuttering behaviors. Incidence and Prevalence About 2.5% of preschool children stutter now (prevalence).26 The incidence of preschool stuttering is about 5%. In other words, about one in twenty of children stutter at some point in childhood. Less than 1% of adults stutter. 0.73%, or about one in 135 adults, was the gure found in a recent study.27 That suggests that about two million Americans stutter. On the other hand: The largest stuttering therapy program, the National Center for Stuttering, has treated about 10,000 stutterers. The second-largest stuttering therapy program, the Hollins Communication Research Institute, has treated about 5,000 stutterers. 28 Less than 400 speech-language pathologists are boardcertied Fluency Specialists. Most treat only a handful of adult stutterers each year. About 2500 Edinburgh Masker anti-stuttering devices were sold in the United States in the 1980s. My company sells about ve hundred anti-stuttering devices each year; SpeechEasy has similar sales. The National Stuttering Association has about two thousand members. The biggest English-language stuttering support e-mail list has about three thousand members.

How many stutterers have you met, out of thousands of people you hear talking every year? I suspect that the number of adult stutterers may be closer to twenty thousand, not two million.

What Is Stuttering? Factors Contributing to Stuttering

21

I wish that I could title this section The Cause of Stuttering. However, more than one hundred years of research has not discovered the cause of stuttering. The following factors are associated with stuttering. Some contribute to stuttering. But others may be effects of stuttering. Speech motor control overactivity, treated with uency shaping therapy (page 80) training you to relax your speechproduction muscles. Auditory processing underactivity, treated with electronic anti-stuttering devices (page 55). Lateralization, i.e., high right-hemisphere activity and low left-hemisphere activity. Laterality training was tried in the 1930s, without success.29 Abnormal dopamine levels, treated with dopamine antagonist medications (page 72). Suboptimal responses to stress, treated with stress management training (page 129). Speech-related fears and anxieties, treated with stuttering modication therapy or psychological counseling (page 149).

There arent clear lines between these factors. For example, the dopamine abnormalities may be the cause of the speech motor control overactivity. Most stuttering therapy programs put stress management and speech-related fears and anxieties together; I believe these are different, because childrens stuttering is affected by stress even if the child does not yet have speech-related fears and anxieties, and the two factors need different treatments. The neurological abnormalities have only been seen in adult stutterers because brain scans have not been done with children who stutter:

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No Miracle Cures
This problem is not merely one of human subjects approval, which places a much higher burden on justifying the use of [brain imaging] with children. The fact is that the typical toddler could not perform the tasks required to make the imaging results interpretable.30

Without brain scans of children before and after the development of stuttering, we cant be sure if neurological abnormalities cause stuttering or are caused by stuttering. The stress-related and other psychological factors associated with stuttering are seen only in adults and older children who stutter. These factors are caused by a child growing up stuttering, and then cause the older child or adult to stutter, i.e., an effect of childhood stuttering becomes a cause of adult stuttering. Speech Motor Overactivity Speech motor overactivity includes overtense respiration (breathing); vocal folds; and lips, jaws, and tongues (articulators). These overtense muscles lock or fail to coordinate, making speech impossible. Not surprisingly, most brain imaging studies of stutterers have found overactivity in the brain areas responsible for speech motor control during speech.31 Fluency shaping therapy (page 80) trains stutterers to speak with relaxed speech production muscles, to counteract overactive speech motor activity. You learn to consciously relax your breathing; vocal folds; and lips, jaw, and tongue. Thats relatively easy. The following chapter (Beyond Fluency Shaping, page 110) addresses the more difcult task of making this uent speech automatic and effortless. Dopamine Abnormalities Stutterers appear to have increased levels of the neurotransmitter dopamine.32 Dopamine antagonist medications diminish stuttering. A controversial study linked stuttering to the three genes that control dopamine levels in the brain.33 The dopamine receptors D1, D2, D3, D4 and D5 are related to

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motor activity.34 Its likely that increased dopamine levels are related to increased speech motor activity. The chapter Dopamine and Anti-Stuttering Medications (page 72) discusses dopamine antagonist medications. Auditory Processing Underactivity Brain imaging studies have found lack of activity in the left superior temporal lobe or auditory processing area during stutterers speech.35 36 There appears to be something wrong with stutterers perception or sensory feedback during speaking. This may be something wrong with how we hear our voices, or an inability to integrate how we hear our voices (auditory perception) and how we feel our muscles moving (somatic perception). Recent anatomical research have found that stutterers brains are physical different from non-stutterers in several areas, including our auditory cortex and in the area that links speech production and perception processing. These differences are believed to cause diminished sensorimotor integration during speech production.37 This auditory processing underactivity was a surprise to most experts in the eld. Traditional stuttering therapies dont treat stutterers auditory processing abnormality, and the treatment electronic anti-stuttering devicesis still controversial.38 In recent years many other disorders, including as dyslexia and autism, have been recently linked to auditory processing abnormalities.39 Like stuttering, it wasnt obvious that these disorders had an auditory processing component until brain imaging research was done. Right Hemisphere Overactivity During speech, the brains of non-stutterers typically show more activity in the left hemisphere, where the brains speech and language areas are located. However, most brain imaging of stutterers have found unusual activity in their right hemispheres during speech.40 These overactive right hemisphere areas include the right frontal

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No Miracle Cures

operculum and the right insula. The homologous areas in the left hemispehere are Brocas area and the left insula, which connects Brocas area to Werneckes area. Brocas area and Werneckes area are the key areas for speech and language in the left hemisphere.41 Its unknown why stutterers use these right-hemisphere areas, unsuited for speech, for speech tasks instead of using the lefthemisphere areas that non-stutterers use. Reactions to Stress Stuttering is a response to stress. We stutter more in stressful situations, when speaking to authority gures, and on the words that convey the most information (pragmatic speech). The more we try to not stutter in stressful situations, the more we stutter. Other disorders with this pattern include Tourettes Syndrome, obsessive-compulsive disorder (OCD), and tics. These disorders were also linked to the genes that control dopamine levels in the brain.42 The chapter Responding to Stress (page 129) presents treatments that teach alternate ways for stutterers to handle stress, that increase uency instead of increasing stuttering. Speech-Related Fears and Anxieties Some adult stutterers fear that if their speech is abnormal or imperfect in any way, listeners will negatively judge them. These stutterers try to hide their stuttering. Some stutterers substitute words they can say for words they fear. Some stutterers avoid talking to strangers, or seek jobs that require no talking. This can become social phobia. Some stutterers refuse to do speech therapy for fear that someone might see them entering a speech clinic, or refuse to do uency shaping therapy because they perceive that the resulting uent speech sounds abnormal. Some stutterers try an anti-stuttering device, then shift their anxiety from listeners hearing stuttering to listeners seeing the anti-stuttering device. Some speech-related fear and anxiety is rational, as listeners experience increased stress when listening to stuttering. Some is healthyyou wouldnt do speech therapy if you had no negative

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feelings about your speech. But when a stutterers speech-related fears and anxieties are more disabling than his stuttering, he needs treatment for his speech-related fears and anxieties (page 149). Multifactorial Treatment No single stuttering therapy is effective for all stutterers. Treating stuttering requires a multifactorial approachdifferent treatments for each factor. And different stutterers may have more or less of each factor, so different stutterers respond better or worse to different treatments. Before the 1990s, speech-language pathologists either believed that stuttering was physical or believed that stuttering was psychological. The former provided uency shaping therapy; the latter provided Iowa therapies. In the 1990s Barry Guitar led a movement to integrate Iowa therapies and uency shaping. Now most stuttering specialists provide such integrated therapy. Such therapy programs address two or three of the factors associated with stuttering. Factors left unaddressed by integrated stuttering therapy include auditory processing underactivity (page 55) and abnormally high dopamine levels (page 73). A truly integrated stuttering therapy program would take these treatments into consideration. Until someone develops such a stuttering therapy program, consumers are left on their own to piece together treatments. You may have to go to several speech clinics to treat all of the factors that contribute to your stuttering.